Inside Health

The Doctor Who Made His Students Wash Up

By HOWARD MARKEL

Published: October 7, 2003

We all expect our doctors to wash their hands before examining us, let alone before performing an operation, to prevent the spread of infection. But surprisingly, the lifesaving power of this simple act was not discovered by physicians until 1847.

Dr. Sherwin B. Nuland, a surgeon and a winner of the National Book Award, brings this discovery to life in his new book, ''The Doctors' Plague: Germs, Childbed Fever and the Strange Story of Ignac Semmelweis'' (Norton/Atlas Books).

Dr. Nuland tells a medical detective story about the ambitious yet troubled physician who figured out how to prevent a deadly infection spread by doctors to childbearing women. It is known as childbed or puerperal (from the Latin words for child and parent) fever.

Dr. Nuland's book, a result of years of study on this topic, is certain to stir up a storm in the normally staid world of medical historians.

Ignac Semmelweis, a Hungarian obstetrician at the famed Vienna General Hospital, is best recalled for exhorting his fellow physicians to wash their hands before examining women about to deliver babies. Unfortunately, few listened.

In the 19th century, roughly 5 women in 1,000 died in deliveries performed by midwives or at home. Alarmingly, when the delivery was performed by doctors in the best maternity hospitals in Europe and America, the death rate for women was often 10 to 20 times as great.

The cause was invariably childbed fever. And a miserable death it was: raging fevers, putrid pus emanating from the birth canal, painful abscesses in the abdomen and chest, and an irreversible descent into an absolute hell of sepsis and death -- all within 24 hours of delivering a baby.

Medical students and their professors at the elite teaching hospitals of Semmelweis's era typically began their day performing autopsies on the women who had died the day before of childbed fever. They then proceeded to the wards to examine the women who were in labor or about to start it.

Soon after being appointed to run the first division of the obstetrics service at the Vienna General Hospital in 1846, Semmelweis became obsessed by the childbed fever epidemics that were killing nearly a third of his patients. He described to another colleague the ''heart-rending scenes'' of women assigned to his ward begging to be discharged because ''they believed that the doctor's interference was always the precursor of death.''

He was wise enough to listen to his patients.

The obstetrician made the brilliant observation that puerperal fever was caused by the transfer of some type of ''morbid poison'' from the dissected corpses in the autopsy room to the women in labor.

Semmelweis was not the first to make the connection. Both Alexander Gordon of Edinburgh and Oliver Wendell Holmes of Boston suggested this mode of transmission in 1795 and 1843, respectively.

The morbid poison is now known as the bacteria called Group A hemolytic streptococcus.

But it was Semmelweis, in 1847, who ordered his medical students to wash their hands in a chlorine antiseptic solution until the smell of the putrid bodies was no longer present.

Soon after, the mortality rates dropped considerably.

Unfortunately, Semmelweis's ideas were not accepted by all of his colleagues. Indeed, many were outraged at the suggestion that they were the cause of their patients' miserable deaths, and Semmelweis met up with enormous resistance and criticism. A remarkably difficult man, he refused to publish his ''self-evident'' findings until 13 years after making them.

Dr. Irvine Loudon, an associate at the Wellcome Unit for the History of Medicine at the University of Oxford and the author of ''The Tragedy of Childbed Fever'' (Oxford, 2000), observed that Semmelweis ''had a temper like a rattlesnake and was outrageously rude to anyone who questioned his ideas.''

Becoming more shrill and angry at each detractor's critique, Semmelweis abruptly left Vienna in 1849 for his native Budapest without even telling those who supported him.

To make matters worse, it was clear by the 1860's that Semmelweis was insane, and he was committed to an asylum where he died in 1865.

One aspect of Dr. Nuland's account certain to make waves is his diagnosis of the exact cause of Semmelweis's death.

Many historians have pointed to an operation that Semmelweis performed as an assistant, infecting himself and dying of blood poisoning. Others have insisted that the doctor died of syphilis, which may explain his insanity.

After reviewing both the autopsy report and findings made when Semmelweis's body was exhumed, X-rayed and examined in 1963, Dr. Nuland makes a compelling case that the obstetrician had Alzheimer's disease and was beaten to death in the asylum by his keepers.

Dr. K. Codell Carter, a professor of philosophy at Brigham Young University and the author of a Semmelweis biography, is less confident of this conclusion.

''Most of the people I've talked to think that the descriptions of Semmelweis's erratic behavior were reported too long after the fact to be reliable,'' Dr. Carter said. ''I think that there isn't too much to go on except the autopsy report, and that really isn't conclusive.''

Dr. Loudon, reflecting on Semmelweis's mental health, added: ''It might have been manic-depressive psychosis (my favorite) or it could have been syphilis (an occupational disease of ungloved obstetricians). But soon after he was admitted to a lunatic asylum, where he was forcibly restrained, he clearly had septicemia.''

Dr. Loudon suggested that the infection originated from a sore on Semmelweis's hand. ''He was maltreated, yes, but he died of sepsis,'' Dr. Loudon added.

Sadly, Semmelweis's timing was awful. Only two years after his death, Louis Pasteur first published his work on the role of bacteria in spoiling wine and gave rise to the era of the germ theory of disease.

A few years later, the Scottish surgeon Joseph Lister, who had never heard of Semmelweis, elaborated the theory and practice of antiseptic surgery, which includes washing the hands with carbolic acid to prevent infection.

In 1876, the German physician Robert Koch successfully linked a germ, Bacillus anthracis, to a specific infectious disease, anthrax.

Asked what fascinated him most about Semmelweis's career, Dr. Nuland said: ''I am obsessed by historical figures who have self-destructed. But I can also identify with the clinical crises he faced, his thinking process and the enormous amount of frustration of not having the answer as to why his patients were dying. Whatever we say about him, he was the classical example of the ideal physician who felt a great obligation to help people who were suffering.''

Since the early 1900's, many medical historians have had high praise for Semmelweis and his work, detailing his struggles, his early death at 47, and the great public debt to him. Yet Dr. Nuland convincingly argues that Semmelweis often harmed himself, insisting that Sophocles would have written it ''with a Greek chorus of dying mothers -- a great hero, a great truth, a great mission, and finally a mad flight of passionate arrogance resulting in destruction.''

''The gods who were the professors of obstetrics did not bring it about,'' Dr. Nuland said. ''The hero brought it on himself.''

Photo: At Vienna General Hospital, Dr. Ignac Semmelweis watched childbed fever kill a third of his patients.